HomeMy WebLinkAboutNCC231045_FRO Submitted_20230414 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable,place N/A in the blank.)
Part A.
1. Project NameTerminix
Transylvania City or TownshipBrevard
2. Location of land-disturbing activity: County
931 Rosman Hwy 36.21829 Lon nude{decimal degrees)
Highway/Street Latitude(decrmei degrees) 9
3. Approximate date land-disturbing activity will commence:04 - 2023 -
4. Purpose of development(residential,commercial, industrial, institutional,etc.):
Commercial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):
1 .75 AC.
6. Amount of fee enclosed: $2OO . The application fee of$100.00 per acre (rounded
up to the next acre)is assessed without a ceiling amount (Example:8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes PI Enclosed 0 No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name
Mike Hoffman E-mail Address mhoffman@trustterminix.com
Phone: Office# (877) 855-4093 Mobile# (803) 730-1258
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Terminix Service Inc. (877)-855-4093 (803) 730-1258
Name Phone: Office# Mobile#
PO Box 2627 3618 Fernandina Rd.
Current Mailing Address Current Street Address
Columbia, SC 29202 Columbia, SC 29210
City State Zip City State - Zip
10. Deed Book No.°°949 Page No.0007 Provide a copy of the most current deed.
I
Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Terminix Service Inc. mhoffman@trustterminix.com
Company Name E-mail Address
3681 Fernandina Rd. 3618 Fernandina Rd.
Current Mailing Address Current Street Address
Columbia, SC 29210 Columbia, SC 29210
City State Zip City State Zip
Phone: Office# (877) 855-4093 Mobile# (803) 730-1258
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry,give name and street address of the Registered Agent:
Terminix Service Inc. sfoust@trusstermininx.com
Name of Registered Agent E-mail Address
105-A Center Lane 3618 Fernandina Rd.
Current Mailing Address Current Street Address
Huntersville, NC 28078 Columbia, SC 29210
City State Zip City State Zip
Phone: Office# 704-593-1992 Mobile# (704) 202-0184
Samuel Foust
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Samuel J. Foust sfoust@trustterminix.com
Name of Registered Agent E-mail Address
105-A Center Lane 105-A Center Lane
Current Mailing Address Current Street Address
Huntersville, NC 28076 Huntersville, NC 28076
City State Zip City State Zip
Phone: Office# (704) 593-1992 Mobile# (704) 202-0184
NA
Name of Individual to Contact(if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name,attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
cvsp M Deul (,s VP Finance, Secretary & Treasurer
Type or print name Title or Authority
/1" Od„U / 3/Io/z 3
Signature Date
I - 'e JOhr r'1 , a Notary Public of the County of fTt e,kictr, (Q
Sou
State of Me4h Carolina, hereby certify that S'u S a-, -00U G qS appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 1v day of I'c?1C,F) , 2g _
(6/
Mary
Seal
My commission expires
JULLEE JOHNSON
Notary Public,State of South Caroms
My Commission Expires 31112031